Provider Demographics
NPI:1861663064
Name:MCCARROLL, KATHLEEN FITZSIMONS (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:FITZSIMONS
Last Name:MCCARROLL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 W JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3204
Mailing Address - Country:US
Mailing Address - Phone:631-864-7337
Mailing Address - Fax:
Practice Address - Street 1:45 W SUFFOLK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2143
Practice Address - Country:US
Practice Address - Phone:631-582-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF 381007363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics